Centering on Coronavirus Podcast: The Threat To Nursing Homes

The New Center · Centering on Coronavirus Podcast:

Although there is so much we still do not know about COVID-19, public health officials and doctors were sharing the same urgent message from the beginning of the outbreak in early 2020: The older you are, the more likely you are to die if you contract the disease.

And yet, somehow, America allowed its nursing homes to become the epicenter of the worst COVID-19 outbreak in the world. According to data analysis from The Foundation for Research on Equal Opportunity, over 40% of those who have died in the U.S. from COVID-19 have been residents or workers in nursing homes or long-term care facilities. On this episode of Centering on Coronavirus, Policy Analyst Aleksandra Srdanovic interviews Gregg Girvan, a Health Care Policy Expert at the FREOPP, on how the high death toll amongst nursing home residents has profound implications for the way we’ve managed the coronavirus pandemic.

For more insights on the impact of COVID-19 on nursing homes, you can read The New Center’s issue brief “COVID-19 in Nursing Homes: How Could We Let This Happen?”


Gregg Girvan: My name is Gregg Girvan. I am the research fellow at the Foundation For Research on Equal Opportunity. I perform a lot of the data analysis that we do, especially on the healthcare side. We had several projects going on even before the coronavirus came onto the scene. Essentially, I dive deep into the different issues with a lot of different aspects of healthcare policy. We’ve been working quite a bit on doing a country by country comparison of healthcare systems. It’s been an ongoing project we’ve been working on for quite a while now, but obviously when the coronavirus hit, we definitely pivoted toward that. And that’s been what we’ve been talking about.

A lot of people are now familiar with our work, given that they’ve seen our comprehensive plan on reopening the economy. Even despite the coronavirus pandemic and this sort of FREOPP plan that we have that has gotten a lot of attention, we were really the first ones to ask the question, if we don’t have an effective treatment, if a vaccine doesn’t come on the scene anytime soon, if at all, and if we have trouble with other things like scaling up testing, what do we do then? Do we just remain locked down, or do we find in the data and what we know about the virus, a way or ways to selectively reopen in certain ways so that we can get as many people as possible back to school, back to work, and still protect those who are most vulnerable.

Out of that plan that we’ve been talking about for a couple of months now, it began to emerge in the data that the nursing home crisis was really starting to become a real problem. When you discover that well over 40% of people have died from the virus so far are nursing home and assisted living residents, and yet they only comprise 0.6% of the population, that gives you a very clear indication that this is an extraordinary problem within nursing homes, but it also informs how we reopened the rest of the economy. It tells us that maybe sort of the optimistic view here is that the fact that so much of the problem is concentrated in nursing homes means that it may not be the same danger or threat to those outside of nursing homes, including those who are elderly, as we perhaps thought before. 

Aleksandra Srdanovic: On the topic of nursing homes, you’ve brought up that statistic of these nursing home and assisted living facility residents accounting for over 40% of deaths. We knew pretty early on into the pandemic that the disease would be particularly deadly for older people with underlying health issues, which of course describes a lot of people who live in nursing homes. I’m wondering if you think local or federal government entities acted too late to protect them. Or do you think that they took action, but it was just inevitable?

Gregg Girvan: Well, there is certainly the thought out there that these particular places were vulnerable prior to the pandemic. And we look at just the hundreds of thousands of people, nursing home residents, who are affected every year by any number of different bacterial or viral pathogens. And this is a pretty common problem just outside of there being the coronavirus. There’s certainly the thought out there that this was a vulnerable population to begin with.

That being said, what we kept hearing as this became a larger and larger problem in the United States was that we have to institute these lockdowns and we have to engage in social distancing and all these other different pandemic tactics that were from this previous playbook for influenza type viruses, where we needed to shut things down in order to prevent our hospitals from being overrun. That was really the main focus was to make sure that hospitals were able to handle the influx of patients that were going to come in, that we’re going to have to take up those ICU beds.

When the original plans were being drawn up by federal state, local governments to deal with the crisis, the focus was completely on hospitals. And unfortunately, that meant that these other areas like nursing homes and assisted living facilities did not get prioritized like our hospitals did. And there was good reason to prioritize the hospitals. And certainly in certain urban areas like New York City, where there was a huge spike in the number of patients and the number of hospitalizations. But it’s become clear looking back that this was an area where really all levels of government, federal, state, local government did not measure up in terms of being able to protect those who truly are the most vulnerable.

You have to think if you look at the people that are in nursing homes and their levels of need, you talked about the comorbidities that these people had. These are people that need a tremendous amount of help. They have a high prevalence of cardiovascular disease, diabetes. You can imagine among this pandemic with people who, for instance, are diabetic and they need to leave their nursing home to have dialysis. You think about the danger that presents for that individual with the coronavirus and this increased likelihood that they would become infected simply because they have to leave the nursing home and undergo dialysis.

And then you look the other way where you have a lot of these healthcare workers in nursing homes that don’t live at the facility obviously, they have lives outside of the facility and oftentimes they would get infected, they’d be asymptomatic and they’d bring the virus right into the nursing home where, because of the congregate nature of nursing homes, where oftentimes residents are sharing a room, sometimes there’s even up to four in one large room, or up to four that are sharing a bathroom, for instance.

And then combine that with the fact that these facilities have had difficulties in the past with infection control and then layer on top of that, the fact that you have an elderly population that has a lot of these comorbidities. It was really a perfect storm for widespread infections and a high fatality rate. This is obviously something that we’re going to have to reckon with as the pandemic one day eventually dies down and we’re looking back and assessing all of this. It’s pretty clear that our model for protecting really the most vulnerable among us, pretty much failed. And we’ve got to make some major changes in order to protect residents from the next pandemic.

Aleksandra Srdanovic: I think that the general perspective on how the federal government states approached the nursing home has been negative. But do you think that there’s any states whose policies have been particularly successful at preventing the spread? Have you found some states that have lower rates of cases and deaths in nursing homes or that have been particularly unsuccessful, or do you think it’s pretty much the same across the board?

Gregg Girvan: Well, for sure, there have been problems with this particular population since the pandemic began pretty much across the United States with certain exceptions. There are a few states, for example, the ones that come to my mind are states like Alaska and Hawaii that haven’t had really any fatalities, or they’ve only had some in the single digits. A part of that simply has to do with the fact that those are populations that are more remote, they’re more removed from where the epicenters of the virus have been.

Contrast that with essentially New England, if you look really far along the I-95 corridor from basically Maryland up through Massachusetts, you’ve had a really high rate of infection and high fatality rates, especially in nursing homes. And part of that simply has to do with the fact that that’s where the epicenter of the virus has been, and the population is more dense there, so you’re going to have more nursing homes there. And on top of that, you’re just going to have the people in closer proximity to one another, so there’s that factor.

If you look at other states though, that do have higher levels of population, for instance, you have a state like Texas or Florida, those couple states have done a reasonably better job of keeping the virus out of their nursing homes. Part of that has to do with the fact that very early on, they made a conscious decision to not send those residents [who had gone to hospitals] back to the nursing home before they were completely clear of the virus.

Then you look at other States like New York, under Governor Cuomo’s orders, you look at a state like Michigan that is still doing this. They are still taking patients that were in nursing homes, they’re treating them in the hospital, and then out of fear that their hospitals would be overrun, that they would not have enough beds, they’re sending these individuals back to the nursing home before they’ve been completely clear to the virus, before they’ve fully recovered. And it’s pretty clear that that has yet another way that the virus has spread throughout these facilities.

A lot of these state governments that have had these orders in the past, or still have them in place now, will say, “We have procedures in place to separate those individuals and to keep them separate from the rest of the nursing home population.” But the fact is there are a lot of nursing homes that were not even equipped to do that and yet they were still being forced to take these patients back into nursing homes.

Really, the first thing that has to be done in order to address the crisis in nursing homes is these orders need to be rescinded. It’s very clear looking at the data that the rate of hospitalizations has for the most part across the country, been on the decline. There are a few states, a few localities where there’s an uptick as testing has increased as the states have opened up. But for the most part, the rates of hospitalizations have been on the decline and there is plenty of capacity in hospitals. These orders need to be rescinded, and that’s first and foremost.

States like Texas and Florida never had those orders in place, and rightly so in order to prevent the infections from starting from those individuals being returned to the nursing home. It’s policies like that that have helped states like Texas and Florida. As I said, going forward, these orders need to be rescinded, but on top of that, there needs to be better protocols put in place for infection control. We need to ensure that these facilities have adequate personal protective equipment for the staff as well. That’s something that, again, we prioritized for hospitals and made sure that we ramped up PPE capacity for hospitals, but nursing homes really became an afterthought. And there are plenty of nursing homes, according to the data that we’ve seen, that either don’t have enough PPE right now, or they don’t have enough to handle a surge in cases within their facilities. Those are some of the things that state and local governments really need to focus on.

Aleksandra Srdanovic: It seems like those reforms are very COVID focused, like providing PPE and making sure that they have these infection protocols in place. But a lot of the issues that the states have had with their COVID-19 policies, it seems like have been exacerbated by a lot of underlying and longstanding issues in how nursing homes are run and regulated, namely underfunding, and it seems like there’s lapses in state inspections and there’s inadequate training for staff. So I’m wondering, what are some of the broader and long term reforms that you feel like are necessary to ensure that these nursing home residents have better living conditions once COVID-19 has passed?

Gregg Girvan: Sure. Aleksandra, you bring up a really good point here. And that is that the problems that we’re seeing in nursing homes in relation to the coronavirus and really in relation to any major disease outbreak is the fact that this has been a longstanding problem and a structural problem that has really been multiple decades in the making. This is also something that I’ve written about recently, where really, you look at the business model of nursing homes, and it really lends itself to the problems that you’re seeing right now, especially in terms of understaffing and in terms of not having adequate infection controls and PPE storage.

What you have to understand is: what is the business model? How are these nursing homes really being run? The idea is to follow the money, as with so many other things. That it’s really about where the money is coming from in order for these nursing homes to operate. Really in this country, most people don’t realize that the oversize role that Medicaid plays in paying for residents in nursing homes.

For nursing home residents, you basically have two subsets of populations. One is those who are going to nursing homes for a specified shorter duration of time in order to recover from a major surgical procedure, say a hip replacement. These people are in there for post-acute care as they call it. These individuals, when they’re elderly, age 65 or older, Medicare is paying for those individuals. And Medicare pays at a much higher reimbursement rate than Medicaid does.

Contrast that with the second subpopulation, and these are the individuals that are in long term care facilities and nursing homes for a longer period of time or indefinitely. And these are individuals that are not necessarily there because they’ve had a surgical procedure or something to that effect, they’re there because they need assistance with what we call activities of daily living or ADLs. And these are things that we often take for granted in our normal, everyday life. But they’re things like walking, dressing, eating, getting in and out of bed, so what they call transferring. These particular individuals need assistance with those kinds of activities, they can’t do them on their own anymore.

These individuals typically are in these facilities fees and are being paid for by Medicaid. And this really has a lot to do with just the way that the Medicaid law has been written over time. And what we find is when nursing homes or when long term care was originally made part of a Medicaid, or it being a service reimbursed by Medicaid, they were just for nursing homes. That was the only thing Medicaid would reimburse for back in the early 1970s. There became what we call institutional bias, where people were getting long term care services and nursing homes only in, really in what we call institutional settings. These are settings that are higher levels of care, and they look a lot more like hospitals, if you look at just the way they’re structured physically.

The thing to remember is that with Medicaid, they’re getting paid at a much lower reimbursement rate. What these nursing facilities often have to do is they have to increase their mix of Medicare patients or patients who are paying through long term care insurance, or simply paying out of pocket in order to cover the residents that are paying through Medicaid, because the Medicaid reimbursement rates often don’t even cover their cost of care.

Nursing homes, because they have such a high level of Medicaid patients on average, 62% of nursing home residents are on Medicaid. When you look at that fact, you could see how they operate on pretty razor thin margins. Then if you layer on top of that  the coronavirus pandemic and how that’s affected that case mix, you still have a lot of these people in there who are on Medicaid, but because the hospitals have been closed to non-elective procedures, the number of residents that are paying through Medicare that are just there for post-acute care has decreased rapidly because nobody’s having those surgical procedures done with the hospitals being closed down. They’re only starting to reopen in certain places now. So that’s a major revenue stream that the nursing homes have also lost out on, on top of the fact that nobody wants to live in a nursing home right now. Understandably so, given the crisis that’s been going on.

Prior to the pandemic, you have a very tenuous and very shaky business model to begin with that has just been blown apart by the pandemic. Going forward, what is this going to look like? What is long term care going to look like? And the answer is we don’t know for sure, but looking at how things are breaking down right now, it’s pretty clear that the demand for living in a nursing home is going to go down even further. The problem again, is that there are certain ways in which the Medicaid Laws are written that’s still biased toward placing people in nursing homes.

They’ve done quite a number of things over the years with Medicaid waivers to try to encourage people to receive these kinds of services in their home or in the community and in a lower impact settings so that they could still receive these services in the community, but not be as intense. But that being said, a lot of those waivers have waiting lists, and there just isn’t enough room for a lot of those people to pull down those services in Medicaid so they still end up in a nursing home anyway, and looking forward, we really have to deal with that. That’s going to be a structural problem that has to be dealt with and reformed one way or another.

We definitely need to introduce more flexibility into the Medicaid programs so that these individuals, at least for now, can seek long term care services in other settings, other than nursing homes. We don’t even know how many nursing homes are going to be around really after the pandemic sort of fizzles out. We just don’t know how many are going to survive, there’s probably going to be a lot of consolidation in the industry as well.

Really, what we need to do is we need to be thinking more holistically and from a 30,000 foot view and say, “How are we going to provide these services to individuals and how are we going to pay for it?” Because clearly the model that we have now is not sustainable. We need to find ways to encourage people to save for this, to increase their uptake of long term care insurance. It’s easier said than done because of the market power so to say that Medicaid has in long term care, but that is going to have to change because of what’s going on on the ground.

Aleksandra Srdanovic: That’s a really fascinating point that you make about the funding structure. I think a lot of people probably don’t know how much of an impact that has on how these nursing homes are run. Thank you for diving deep into that. I think those are all the big points that I wanted to cover with you on my end, unless you think that there’s anything that we missed that you thought was really insightful or important to bring up?

Gregg Girvan: The last thing that I would mention is the fact that throughout this whole thing, it’s been very difficult to obtain data as somebody who works with this on a daily basis. It’s been difficult to find what’s been going on in certain states and even in States like Michigan, where again, they still have these orders in place to send recovering patients back to nursing homes, and yet, you can’t even get accurate numbers from the state in terms of how many people are infected, how many fatalities have happened in these different facilities.

Now, CMS is really trying to obtain this data. And in early May, they put that into place where all the nursing homes that we’re receiving either Medicare or Medicaid funding were required to report to CMS on data points, such as the ones I’ve mentioned. And the thing to remember about that is that that rollout has been shaky. It’s been… The data that they have out right now is not accurate, or at least that the level of accuracy that we want to see. We’ve been diving into this data, and for instance, there have been nursing homes that somehow reported that they had five, six, 700 fatalities in their nursing homes. And yet these are nursing homes that may only have a hundred or 150 that’s to begin with.

Some of the data has not been released to the public properly, so we just have to wait for that and wait for those corrections in order for us to give a better idea, or at least for that comprehensive nationwide reporting to give us some clearer pictures, but we should be getting better updates in the coming weeks as we go.

That being said, again, at the Foundation for Research on Equal Opportunity, we’ve been going really state by state and finding this data. And again, most underappreciated fact or statistics in this whole pandemic is the fact that again, over 40%… according to our calculations, over 42% of people who have died from the virus have died in nursing homes, and they only make up 0.6% of the entire US population. And because of that, we know that we can take steps to reopen the economy, to reopen schools, because it’s a much less significant threat to those populations than it is to say folks in nursing homes.

This is really the most under-appreciated statistic, and once people really understand that it will help to inform the policy decisions that we make going forward so that we can still protect the most vulnerable without completely wrecking the economy with tens of millions of that are unemployed. These are things that we can prevent to begin to repair the country.

Aleksandra Srdanovic: Right. Thank you so much, Gregg. I really appreciate you taking the time. This has been really insightful.

Gregg Girvan: Absolutely. Well, it was my pleasure. Thank you for having me.

This transcript has been edited for length and clarity.